PRINCIPLES OF MANAGEMENT

AND PREVENTION OF
ODONTOGENIC INFECTIONS
 One of the difficult problems in Dentistry
 caries, pulpitise periodontal disease
 Range from Low grade well Localized to life
threatening deep facial space infections
 pathway
 causative micro organisms
Microbiology of odontogenic infections

 bacteria normally part of the normal flora

 these are primarily aerobic gram positive
cocci, anaerobic gram positive cocci,
anaerobic gram negative rods
 these cause different problems and diseases
in the oral cavity
 These bacteria gain access to deeper tissues
through the pulp or through the periodontal
ligament
 All odontogenic infections are caused by
multiple bacteria (poly microbial nature)
 Oxygen tolerance of the bacteria cause
odontogenic infections
 anaerobic only50%
 aerobic only 6%
 mixed 50%
Predominant aerobic bacteria

 STREPTOCOCCUS MILLERI which consist of

3 no.
 S. VIRIDANS GROUOP
 S.ANGINOSUS
 S.INTERMEDIUS
 ## can grow in the presence and the absence
of oxygen
Anaerobic bacteria

 greater variety of species

 ¥¥ anaerobic gram positive Cocci
 ¥¥ gram negative rods
Mixed infection

 after the initial inoculation to deeper tissues

the aerobic bacteria spread through the
connective tissue which initiate Cellulites
type of infection
 metabolic by product create a favourable
environment for the growth of anaerobes
 Release of essential nutrients, Lowered PH
and consumption of Local oxygen allow
excellent environment for anaerobes

 anaerobes cause liquefaction nerosis by

collagenases
 collagen is broken down, invading white
blood Cells necrose and lyse this end with
abscess formation
so

 in the abscess stage the anaerobeS

predominate but in early infection (cellulites)
the aerobes predominate
So the progression from aerobic to anaerobic
infection give four clinical stages of infection

 1st 3 days: soft mildly tender, dough swelling which

represent the inoculation stage(Edema)

 after 3to5 days the swelling become hard, red and acutely
tender ( Cellulites)

 after 5-7 days liquefied abscess in the center of the

swollen area (abscess)
 Finally if drainage occur (resolution stage)
Progression of odontogenic infections

 two major origins:-

---- PERIAPICAL:- pulp necrosis
---- periodontal:- deep pocket

the 1st one is the most Common

 Endodontic treatment or extraction of the
tooth is very important in addition to
Antibiotic in order to treat the patient
When the infection erode the cortical plate of
the alveolar process, it will spread into
predictable anatomic location
The location of infection from a specific
tooth is determined by

 1- the thickness of the bone overlying the

apex
 2- the relationship of the site of perforation to
the muscle attachment off maxilla and
mandible
Pic 15 -1
The location of th infection in soft tissue

 determined by muscle attachment

 Pic15-2
 Most maxillary teeth erode through the facial
cortical plate below the muscle attachment
 so most of maxillary dental abscess appear as
vistibular abscess
 occasionally palatal abscess from the apex of
the upper lateral or palatal roots of the upper
four or molars
Pic15-3-4-
 It is very common that maxillary molars cause
infections which erode above the buccinators
muscle attachment which leads to buccal
space infection

 the long root of the upper Canine may cause

Infra orbital infection since it allow the
infection to erode above the attachment of
levator anguli oris m.(Canine space infection)
Mandible

 Infection from the incisors, Canine, premolars

usually erode through the facial cortical plate
superior to the attachments j the lower lip
muscles which result in vestibular abscess
 Mandibular molar teeth infections erode
through the lingual cortical bone more
frequently than the anterior teeth
 1st molar infections may drain bucally or
lingnally but more lingnally
 lower 3rd molar almost always erode lingnally
 The myolohyoid muscle determines whether
infections that drain lingnally go to
sublingual or sub mandibn for spaces
 The vestibular space abscess is the most
common deep facial space infection
Chronic sinus tract

 Intra orally or in the skin

 Antibiotic stop the active drainage but it will

recur
 so the Treatment is by Treating the cause of
infection and Antibiotic
 the presence of this tract lower the pain
without swelling but if closed the patient will
complain of pain and swelling
 Principles of therapy
 1-Determine severity of infection (history and
physical examination
 2-Evaluate the patient host defence
mechanisms
 3-GP or maxillofacial surgeon
 4- Treat surgically
 5- support patient Medically
 6- Appropriate Antibiotic
 7- rout of Adimistratim
 8- Evaluate the Patient frequently
1-Determine severity of
infection
 complete history:-
 C/C:- I have toothache, my Jaw is swollen,]
have gum boil in my mouth
 onset, swelling or drainage, rapidity of
progression
 we should ask about the symptoms of
inflammation:- dolor(pain), tumur (swelling),
Calor (warmth), rubor(erythema,redness)
and loss of function
 We should ask about the patient general
condition ( patient, who feel fatigued
‘feverish, weak and sick (malaise)
 We should ask about any treatment
 Physical examination
 1st of all we should obtain the patient vital
signs (temperature, blood pressure, pulse
rate, and respiratory rate inorder to evaluate
the systemic involvement of the infection
 Temperature more than 38.3 indicate severe
infection
 Pulse rate more than loo beat/ min indicate
severe infection and require aggressive
management
 the blood pressure is the least affected vital
sign with infection…..>>> pain an anxiety>>>
increase in blood pressure, however the
septic shock cause severe hypotension
 Respiratory rate should be closely observed
 normal from 14-16
 pt with mild to moderate
infection>>>>RR>18 breath/ min
 General appearance of the patient
 Head and neck examination . Check for
trismus, dysphasia and dyspnea ( any
problem here indicate severe infection and
the pt. should be referred to Emergency
room or to maxillofacial surgeon
 We should examine the swelling >>>
>>> overlying erythema,>>>>tenderness>>>>>>
consistency of the swelling>>> soft(DAUGHY
FEELING) or hard (indurated)or fluctuant
(fluid filled balloon )
 Intra oral examination to find the cause

 Radiograph
After Examination

 soft mildly tender edematons

swelling>>>>>>>> inoculation stage

 induration>>> cellulites

 fluctuant>>>>> abscess
 Treatment
 edema.. Remove the cause with or without
Antibiotic
 cellulites and abscess>>> *Removing the
causes I and D with suitable Antibiotic
Principle 2

 Evaluate the patient’s Defense mechanisms

 Several diseases and drugs may Compromise
this ability
 Medical conditions that Compromise the
patient’s defense
Uncontrolled metabolic
diseases
 poorly controlled diabetes

 Acoholisims

 malnutrition

 End stage renal disease

Immune system suppressing
diseases
 HIV

 lymphoma and leukemias

 other malignancies

 congenital and acquired immunologic

diseases
Immuni suppressive therapies

 chemotherapy

 corticosteroids

 organ transplantation
Principle 3

 Determine whether patient

should be treated by a
dentist or to be referred
 Most infections are recognised by the dentist

 most of them are easy to manage

 But it is very important to recognise the

Potential severity of the infection
Criteria for referral to
maxillofacial surgeon
 Difficulty in breathing
 Difficulty swallowing
 dehydration
 moderate to severe trismus less than 20 mm
 elevated temperature
 toxic appearance
 compromised host defense
 need for General aneasthesin
 failed treatment
 Extra oral facial spaces
Immediate referal to
hospital
 rapidly progressing infection since this type
may reach the deep facial spaces

 difficulty in breathing(DYSPNEA)
 DYSPHAGIA
 It is always best to err on the side of caution
Principle 4

 Treat Infection surgically

 The primary principle is to perform surgical
drainage and to remove the cause of
infection(necrotic pulp or periodontal pocket)
 this may range from Endo access opening to
wide Incisions in the neck regions
Typical odontogenic
infection
 carious tooth with pericarpial radiolucency
and vestibular abscess
 Incision of the abscess or cellulites allows
removal of the accumulated pus and so
decompression of the tissue
 and this will increase the blood supply to the
infected area
 Insertion of drain is very important to
prevent premature closure
.
Indications for C and s

 Infections beyond alveolar process

 rapidly progressive infections
 previous multiple antibiotic therapy
 non responsive infection
 recurrent infection
 compromised host defence
 After making the incision, we should insert a
curved haemostat into the abscess cavity
 then it should be opened in several direction
 power suction is very important
 then we insert the drain, the most commonly
used is the Penrose drain , should be sutured
to one end of the wound
 Drain left 2-4 days
Principle 5

 support the patient Medically

 Immuni system compromise

 control of systemic diseases

 physiologic reserves
Immuni compromised patients

 specialist
 hospitalization
 medical consultation
 oral intake or IV fluids to treat dehydration
due to high fever
 warm applications
 head up position
 analgesia
 rest
 (6)Choose and perscribe
Appropriate Antibiotic

 must be done carefully

Determine the need of
Antibiotic Adimistration
 Seriousness of infection
 is adequate surgical treatment can be
achieved
 mechanism of patients defence
Indications

 swelling beyond the alveolar process

 Cellulites
 Trismus
 lymphadenopthy
 high temperature
 severe pericoronitis .
 osteomyelitis
No need for Antibiotic

 Toothache
 peri apical abscess (well Localized chronic)
 Dry socket
 multiple extraction in Medically fit patients
 mild pericoronitis
 Drained alveolar abscess
(7)Patient evaluation
Deep facial space infections

 muscle attachment
 facial spaces: are fascia lined tissue
compartment filled with loose areolar
Connictive tissue that become inflamed
when invaded by bacteria
Spread of infection

 directly

 lymph node

 blood stream
 Infection from maxillary
teeth

 Infra orbitaL

 palatal

 orbital infra temporal

 and maxillary sinus

Mandibular teeth

 Sub mandibular

 sub lingual

 sub mental

 and masticator spaces

 Infection can extend from These primary
spaces into deeper facials Spaces as retro
pharyngeal Lateral pharyngeal, carotid, pre
tracheal and to mediastinum

 Infection may extend superiorly to

Covernons sinus and brain
 Deep facial spaces
associated with any tooth

 vestibular
 Buccal
 subcutaneous
Deep spaces associated with
me maxillary teeth

 Infra orbital
 Buccal
 Infra temporal
 maxillary and other sinuses
 Covernouns sinus thrombosis
 Deep facial spaces
associated with mandibular
 teeth

 sub mandibular, sublingual, sub mental,

masticator spaces sub mesenteric,
pterygomandibular superficial temporal,
deep temporal
 Deep facial spaces of the
neck

 Lateral pharyngeal
 retro pharyngeal
 Pre tracheal
 danger space
 prevertebral
 vestibular
Buccal
Low severity
Infra orbital

 Moderate severity  High severity

sub mandibular, sub
lingual, sub mental,
Masticator, sub massetric,
pterygomandibular,
superficial temporal “Deep
temporal
deep neck spaces, lateral
pharyngeal, retro
pharyngeal, pre tracheal,
danger space,
mediastinum, Covernons
sinus thrombosis,ludwigs
angina
 Each of these pathologic conditions is
described including discussion of their
anatomic location, etiology, clinical
presentation, and therapeutic treatment
Abscess of Base of Upper Lip

 Anatomic Location.
This abscess develops
at the loose connective
tissue of the base of
the upper lip at the
anterior region of the
maxilla, beneath the
pearshaped aperture
 Etiology. It is usually
caused by infected root
canals of maxillary anterior
teeth.
 Clinical Presentation.
What characterizes this
infection is the swelling and
protrusion of the upper lip,
which is accompanied by
diffuse spreading and
obliteration of the depth of
the mucolabial fold
 Treatment. The incision for
drainage is made at the
mucolabial fold parallel to the
alveolar process
 . A hemostat is then inserted
inside the cavity, which reaches
bone, aiming for the apex of the
responsible tooth, facilitating
the evacuation of pus .
 After drainage of the abscess, a
rubber drain is placed until the
clinical symptoms of the
infection subside
Canine Fossa Abscess

 Anatomic Location.
 The canine fossa,
which is where this
type of abscess
develops, is a small
space between the
levator labii superioris
and the levator anguli
oris muscles
 Etiology.
 Infected root canals of premolars and
especially those of canines of the maxilla are
considered to be responsible for the
development of abscesses of the canine
fossa.
 Clinical Presentation.
 This is characterized by edema,
localized in the infraorbital region,
which spreads towards the medial
canthus of the eye, lower eyelid,
and side of the nose as far as the
corner of the mouth. There is also
obliteration of the nasolabial fold,
 . The edema at the infraorbital
region is painful during palpation,
and later on the skin becomes taut
and shiny due to suppuration,
while its color is reddish
 Treatment.
 The incision for drainage is performed intraorally at
the mucobuccal fold (parallel to the alveolarbone), in
the canine region
 A hemostat is then inserted, which is placed at the
depth of the purulent accumulation until it comes
into contact with bone while the index finger of the
nondominant hand palpates the infraorbital margin.
 Finally, a rubber drain is placed, which is stabilized
with a suture on the mucosa
Buccal Space Abscess

 Anatomic Location.
 The space in which this abscess
develops is between the
buccinator and masseter muscles
 (Superiorly, it communicates
with the pterygopalatine space;
inferiorly with the
pterygomandibular space.
 The spread of pus in the buccal
space depends on the position of
the apices of the responsible
teeth relative to the attachment
of the buccinator muscle.
 Etiology.
 The buccal space abscess may originate
from infected root canals of posterior teeth of
the maxilla and mandible
 Clinical
Presentation.
 It is characterized by swelling of
the cheek, which extends from the
zygomatic arch as far as the
inferior border of the mandible,
and from the anterior border of the
ramus to the corner of the mouth.
 The skin appears taut and red, with
or without fluctuation of the
abscess which, if neglected, may
result in spontaneous drainage.
 Treatment.
 Access to the buccal space is usually
intraoral for three main reasons:
 1. Because the abscess fluctuates intraorally
in the majority of cases.
 2. To avoid injuring the facial nerve.
 3. For esthetic reasons.
 The intraoral incision is made at the posterior region
of the mouth, in an anteroposterior direction and
very carefully in order to avoid injury of the parotid
duct.
 A hemostat is then used to explore the space
thoroughly.
 An extraoral incision is made when intraoral access
would not ensure adequate drainage, or when the pus
is deep inside the space. The incision is made
approximately 2 cm below and parallel to the inferior
border of the mandible.
Infratemporal Abscess

 Anatomic Location.
 The space in which this abscess develops
is the superior extension of the
pterygomandibular space.
 Laterally, this space is bounded by the
ramus of the mandible and the temporalis
muscle, while medially, it is bounded by
the medial and lateral pterygoid muscles,
and is continuous with the temporal
fossa . Important anatomic structures,
such as the mandibular nerve, mylohyoid
nerve, lingual nerve, buccal nerve, chorda
tympani nerve, and the maxillary artery,
are found in this space. Part of.the
pterygoid venous plexus is also found
inside this space.
 Etiology.
 Infections of the infratemporal space may
be caused by infected root canals of posterior
teeth of the maxilla and mandible, by way of
the pterygomandibular space, and may also
be the result of a posterior superior alveolar
nerve block and an inferior alveolar nerve
block.
 Clinical
Presentation.
 Trismus and pain during
opening of the mouth with
lateral deviation towards the
affected side,
 edema at the region anterior
to the ear which extends
above the zygomatic arch, as
well as edema of the eyelids
are observed
 Treatment.
 The incision for drainage of the abscess is
made intraorally, at the depth of the
mucobuccal fold, and, more specifically,
laterally (buccally) to the maxillary third
molar and medially to the coronoid process,
in a superoposterior direction
 A hemostat is inserted into the suppurated
space, in a superior direction.

 Drainage of the abscess may be performed

extraorally in certain cases. The incision is
performed on the skin in a superior direction,
and extends approximately 3 cm. The
starting point of the incision is the angle
created by the junction of the frontal and
temporal processes of the zygomatic bone.
Temporal Abscess

 Anatomic Location.
 The temporal space is the superior continuation of the
infratemporal space.
 This space is divided into superficial and deep temporal
spaces.
 The superficial temporal space is bounded laterally by
the temporal fascia and medially by the temporalis
muscle,
 while the deep temporal space is found between the
medial surface of the temporalis muscle and the
temporal bone.
 Etiology. Infection of the temporal space is
caused by the spread of infection from the
infratemporal space, with which it communicates.

 Clinical Presentation. It is characterized by

painful edema of the temporal fascia, trismus
(the temporalis and medial pterygoid muscles are
involved), and pain during palpation of the
edema.
 Treatment.
 The incision for drainage is performed
horizontally, at the margin of the scalp hair and
approximately 3 cm above the zygomatic arch.

 It then continues carefully between the two

layers of the temporal fascia as far as the
temporalis muscle.
 A curved hemostat is used to drain the abscess.
Submental Abscess

 Clinical Presentation.
 The infection presents
as an indurated and
painful submental
edema, which later
may fluctuate or may
even spread as far as
the hyoid bone.
Submental Abscess

 Anatomic Location.
 The submental space in which
this abscess develops mylohyoid
muscle, laterally and on both sides
by the anterior belly of the
digastricmuscle, inferiorly by the
superficial layer of the deep
cervical fascia that is above the
hyoid bone, and finally, by the
platysma muscle and overlying
skin.
 This space contains the anterior
jugular vein and the submental
lymph nodes.
 Etiology.
 Infection of the submental space usually
originates in the mandibular anterior teeth or
is the result of spread of infection from other
anatomic spaces (mental, sublingual,
submandibular).
 Treatment.
 After local anesthesia is
performed around the
abscess , an incision on the
skin is made beneath the
chin, in a horizontal
direction and parallel to the
anterior border of the chin).
 The pus is then drained in
the sameway as in the other
Sublingual Abscess

 There are two sublingual spaces above the

mylohyoid muscle, to the right and left of the
midline.

 These spaces are divided by dense fascia.

 Abscesses formed in these spaces are known

as sublingual abscesses.
 Etiology.

The teeth that are most commonly responsible for

infection of the sublingual space are the
mandibular anterior teeth, premolars and the first
molar, whose apices are found above the
attachment of the mylohyoid muscle.

Also, infection may spread to this space from other

contiguous spaces with which it communicates
(submandibular, submental, lateral pharyngeal).
Anatomic Location.
 The sublingual space is bounded
superiorly by the mucosa of the floor
of the mouth, inferiorly by the
mylohyoid muscle, anteriorly and
laterally by the inner surface of the
body of the mandible, medially by the
lingual septum, and posteriorly by the
hyoid bone.

 This space contains the

submandibular duct (Wharton’s duct),
the sublingual gland, the sublingual
and lingual nerve, terminal branches
of the lingual artery, and part of the
submandibular gland.
 Clinical Presentation.

 The abscess of the sublingual space presents

with characteristic swelling of the mucosa of
the floor of the mouth, resulting in elevation of
the tongue towards the palate and laterally
 The mandibular lingual sulcus is obliterated and
the mucosa presents a bluish discoloration.
 The patient speaks with difficulty, because of
the edema, and movements of the tongue are
painful.
 Treatment

 The incision for drainage is performed

intraorally, laterally, and along Wharton’s
duct and the lingual nerve
 In order to locate the pus, a hemostat is used
to explore the space inferiorly, in an
anteroposterior direction and beneath the
gland
 After drainage is complete, a rubber drain is
placed
Submandibular Abscess

 Anatomic Location.
 The submandibular space is
bounded laterally by the inferior
border of the body o the mandible,
medially by the anterior belly of the
digastric muscle, posteriorly by the
stylohyoid ligament and the
posterior belly of the digastric
muscle, superiorly by the mylohyoid
and hyoglossus muscles, and
inferiorly by the superficial layer of
the deep cervical fascia
 This space contains the
submandibular salivary gland and
the submandibular lymph nodes.
 Etiology.

 Infection of this space may originate from

the mandibular second and third molars, if
their apices are found beneath the
attachment of the mylohyoidmuscle.
 It may also be the result of spread of
infection from the sublingual or submental
spaces.
 Clinical Presentation.
 The infection presents as
moderate swelling at the
submandibular area, which
spreads, creating greater
edema that is indurated and
redness of the overlying skin
 Also, the angle of the
mandible is obliterated, while
pain during palpation and
moderate trismus due to
involvement of the medial
pterygoid muscle are observed
as well.
Treatment.
 The incision for drainage is
performed on the skin,
approximately 1 cm beneath and
parallel to the inferior border of
the mandible During the incision,
the course of the facial artery and
vein (the incision should be made
posterior to these) and the
respective branch of the facial
nerve should be taken into
consideration.
 A hemostat is inserted After
drainage,
 a rubber drain is placed
Submasseteric Abscess

 Anatomic Location.
The space in which this
abscess develops is cleft-
shaped and is located
between the masseter
muscle and the lateral
surface of the ramus of the
mandible Posteriorly it is
bounded by the parotid
gland, and anteriorly it is
bounded by the mucosa of
the retromolar area.
 Etiology.

 Infection of this space originates in the

mandibular third molars (pericoronitis), and
in rare cases because of migratory abscesses.
 Clinical Presentation.
 It is characterized by a firm edema
that is painful to pressure in the
region of the masseter muscle,
 which extends from the posterior
border of the ramus of the mandible
as far as the anterior border of the
masseter muscle
 Also, severe trismus and an inability
to palpate the angle of the mandible
are observed. Intraorally, there is
edema present at the retromolar
area and at the anterior border of the
ramus. This abscess rarely fluctuates,
while it may present generalized
symptoms.
Treatment.
 Treatment of this abscess is
basically intraoral, with an
incision that begins at the
coronoid process and runs along
the anterior border of the ramus
towards the mucobuccal fold,
approximately as far as the
second molar.
 The incision may also be
performed extraorally on the skin,
beneath the angle of the
mandible
 often it is difficult to drain the area
well, resulting in frequent relapse.
Pterygomandibular Abscess

 Anatomic Location.
 This space is bounded laterally by the
medial surface of the ramus of the
mandible, medially by the medial
pterygoid muscle, superiorly by the lateral
pterygoid muscle, anteriorly by the
pterygomandibular raphe, and posteriorly
by the parotid gland
 The pterygomandibular space contains the
mandibular neurovascular bundle, lingual
nerve, and part of the buccal fat pad.

 It communicates with the pterygopalatal,

infratemporal, submandibular, and lateral
pharyngeal spaces.
 Etiology.

 An abscess of this space is caused mainly by

infection of mandibular third molars or the
result of an inferior alveolar nerve block, if the
penetration site of the needle is infected
(pericoronitis).
 Clinical Presentation.
 Severe trismus and slight extraoral edema
beneath the angle of the mandible are
observed.
 Intraorally, edema of the soft palate of the
affected side is present, as is displacement of
the uvula and lateral pharyngeal wall,
 difficulty in swallowing.
 Treatment.
 The incision for drainage is
performed on themucosa of the
oral cavity and,more specifically,
along the mesial temporal crest
 The incision must be 1.5 cm long
and 3–4 mm deep.
 A curved hemostat is then
inserted, which proceeds
posteriorly and laterally until it
comes into contact with the
medial surface of the ramus. The
abscess is drained, permitting the
evacuation of pus along the shaft
of the instrument.
Lateral Pharyngeal Abscess

 Anatomic Location.
 The lateral pharyngeal space is conical
shaped, with the base facing the skull while
the apex faces the carotid sheath.
 It is bounded by the lateral wall of the
pharynx, the medial pterygoid muscle, the
styloid process and the associated
attached muscles and ligaments, and the
parotid gland
 The lateral pharyngeal space contains the
internal carotid artery, the internal jugular
vein with the respective lymph nodes, the
glossopharyngeal nerve, hypoglossal
nerve, vagus nerve, and accessory nerve. It
communicates directly with the
submandibular space, as well as with the
brain by way of foramina of the skull.
 Etiology.

 Infections of this space originate in the

region of the third molar and are the result of
spread of infection from the submandibular
and pterygomandibular spaces.
Clinical Presentation

 . Extraoral edema at the lateral region of

the neck that may spread as far as the tragus
of the ear,
 displacement of the pharyngeal wall, tonsil
and uvula towards the midline,
 pain that radiates to the ear,
 trismus, difficulty in swallowing,
 significantly elevated temperature, and
generally malaise are noted.
 Treatment.
 Drainage is performed extraorally (similar to that of the
submandibular abscess) with an incision 2 cm long, inferior to or
posterior to the posterior part of the body of the mandible.
 Access is achieved using a hemostat, which, after entering the center
of the purulent collection, proceeds towards the medial surface of the
mandible, to the third molar area, and if possible, behind that area.
 The rubber drain that is placed remains in position for about 2–3days.

 Drainage of the abscess may also be performed intraorally, although

it is difficult and risky, because there is a great chance of aspiration of
pus, especially if the procedure is carried out under general
anesthesia.
Retropharyngeal Abscess

 Anatomic Location.
 The retropharyngeal space is
located posterior to the soft
tissue of the posterior wall of the
pharynx and is bounded anteriorly
by the superior pharyngeal
constrictor muscle and the
associated fascia, posteriorly by
the prevertebral fascia, superiorly
by the base of the skull, and
inferiorly by the posterior
mediastinum
 Etiology. Infections of this space originate
in the lateral pharyngeal space, which is close
by.
Clinical Presentation.

 The same symptoms as those present in the

lateral pharyngeal abscess appear clinically, with
even greater difficulty in swallowing though, due to
edema at the posterior wall of the pharynx.
 If it is not treated in time, there is a risk of: 􀁏
Obstruction of the upper respiratory tract, due to
displacement of the posterior wall of the pharynx
anteriorly. 􀁏 Rupture of the abscess and aspiration
of pus into the lungs, with asphyxiation resulting. 􀁏
Spread of infection into the mediastinum.
 Treatment.

 Therapy entails drainage through the

lateral pharyngeal space, which is where the
infection usually begins.
Parotid Space Abscess

 Anatomic Location. The

space in which this abscess develops
is located in the area of the ramus of
the mandible and, more specifically,
between the layers of the fascia
investing the parotid gland.
 It communicates with the lateral
pharyngeal and the submandibular
spaces.
 It contains the parotid gland and its
duct, the external carotid artery, the
superficial temporal and facial artery,
the retromandibular vein, the
auriculotemporal nerve, and the facial
nerve.
 Etiology.

 Infection of this space originates from

odontogenic migratory infections of the
lateral pharyngeal and submandibular spaces.
Clinical Presentation.
 edema of the retromandibular
and parotid region,
 difficulty in swallowing and pain
mainly during chewing, which
radiates to the ear and
temporal region.
 In certain cases there is redness
of the skin and subcutaneous
fluctuation
 Also, a purulent exudate may
be noted from the papilla of the
parotid duct after pressure is
applied.
 Treatment.
 Depending on the margins of the edema
therapy entails a broad incision posterior to
the angle of the mandible .taking particular
care not to injure the respective branch of the
facial nerve.
 Drainage of pus is achieved after blunt
dissection using a hemostat to explore the
purulent collection
Ludwig’s Angina

 Anatomic Location.
Ludwig’s angina is a acute
infection and is characterized
by bilateral involvement of the
submandibular and sublingual
spaces, as well as the
submental space
 In the past this condition was
fatal, although today adequate
surgical treatment and
antibiotic therapy have almost
eliminated fatal episodes.
 Etiology.
 The most frequent cause of the disease is
periapical or periodontal infection of
mandibular teeth, especially of those whose
apices are found beneath the mylohyoid
muscle.
Clinical Presentation
 . The disease presents with severe difficulty in swallowing, speaking
and breathing,
 drooling of saliva,
 and elevated temperature.
 The bilateral involvement of the submandibular spaces and submental
space results in severe and painful indurated board-like hardness,
without apparent fluctuation, because the pus is localized deep in the
tissues
 while the bilateral involvement of the sub-lingual spaces causes painful
indurated edema of the floor of the mouth and the tongue
 The middle third of the tongue is elevated towards the palate while the
anterior portion projects out of the mouth.The posterior portion
displaces the edematous epiglottis posteriorly, resulting in obstruction
of the airway.
 Treatment.
 This is treated surgically with surgical
decompression (drainage) of the spaces of
infection and concurrent administration of a
double regimen of antibiotics.
 Surgical intervention must be attempted to drain
all the abscessed spaces.
 The incisions must be bilateral, extraoral, parallel,
and medial to the inferior border of the mandible,
at the premolar and molar region , and intraoral,
parallel to the ducts of the submandibular glands.
 Exploration and an attempt to communicate with
the spaces of infection, by breaking the septa
dividing them and drainage of the contents, are
achieved with these incisions.
 Rubber drains are placed in order to keep the
drainage sites open for at least 3 days, until the
clinical symptoms of the infection have resolved
 Many people believe that in the case of continued
obstruction, a surgical airway must be
established.
Covernons sinus thrombosis

 When the maxillary odontogenic infections

erode inito the infra orbital vein in the infra
orbital space or the inferior opthalmic vein
with sinuses.
 they can follow the common opthalmic vein
through the superior orbital fissure and then
to the cavernous sinus.
 this will result in cavernous sinus thrombosis
 Very rare from dental origin
 It is a serious life threatening infection
 It has high mortality rate
 require immediate medical and surgical
treatment
Principles of prevention of
infections

 by giving suitable Antibiotic

Principles of prophylaxis of
wound infection
 effective in certain situation
 advantages
reduce the incidence of post operative
infection and morbidities
reduce the cost of health care
reduce the use of Antibiotic
 Disadvantages
alter host flora( increase the pathogenic
bacteria )
Antibiotic resistance
no need for Antibiotic
side effects of the drug
Principles of Antibiotic
prophylaxis
 1- procedure should have
significant risk of
infection

 simple extraction ,frenectomy, and other

minor procedures>>> noneed for prophylaxis
Factors that may affect the
rate of infection
 the presence of infection
 prolonged Surgery more than 4 hours
 the presence of foreign body as dental
implant
 host defense
Choose correct Antibiotic

 should be effective against the

Microorganisms in the oral cavity
 should be narrow spectrum inorder to
reduce the alteration in the normal flora
 the least toxic
 bactericidal
 Penicillin is the most effective narrow
spectrum, low toxicity, and bactericidal
 the 2nd drug of choice is the clindamycine but
it is bacteriostatic so given to allergic
patients
Principle 3 Antibiotic
plasma level must be high

 two times the therapeutic dose before

surgery
Correct administration

 two hrs before surgery and depend on the

rout of administration
Shortest AB exposure